Reports
Core Definitions
Information Sources
The reports primarily draw their data from the following core tables:
Eligibility: This table captures comprehensive membership details, including demographics, revenue, budgets, risk scores, and contact information, to name a few.
Medical Claims: This table contains detailed information about Medical Claims, encompassing service dates, payment dates, diagnoses, provided services, provider details, paid amounts, and more.
Pharmacy Claims: This table contains detailed information about Pharmacy Claims, offering data on service and payment dates, prescribers, providers, specific drug names, and so forth.
Dental Claims: This table contains detailed information about Dental Claims containing data on service and payment dates, providers, and service codes.
Hospital Admissions: This table contains detailed information about Hospital Admissions, with data on enrolled members, hospitals, diagnoses, and admitting physicians.
Member Registries: This table contains detailed information on members enlisted in various plan registries tailored to particular conditions.
Obstetrics: This table contains detailed information on members who are part of the plan's obstetric registry.
Preauthorizations: This table contains detailed information on data pertinent to medical preauthorizations.
Quality: This table contains detailed information about Quality metrics, identifying potential gaps in care.
Naming Conventions of Core Reports
Details Reports
Each of our core tables is mirrored by a corresponding 'Detail Report'. Serving as a reflection of its parent table, every Detail Report carries the nomenclature of its core table, suffixed with 'Details'. For instance, the 'Eligibility' core table is paired with its counterpart, 'Eligibility Details'.
The following are our core Detail Reports:
Eligibility Details
Medical Claims Details
Pharmacy Claims Details
Dental Claims Details
Hospital Admissions Details
Member Registries Details
Obstetrics Details
Quality Measures Details
Each Detail Report captures a one-to-one representation of its corresponding core table's rows. This ensures that you are always a click away from the foundational data. As a navigation hallmark, the vast majority of our reports drill down to these Details, granting you unparalleled access and insights.
Detail Dashboard Reports
Every Detail Report integrates with a dedicated 'Dashboard Report'. Serving as a condensation of raw data, these Dashboards include essential metrics, providing you with an insightful snapshot of the source data. Taking 'Eligibility Details' as an example, its analytical power is further elevated through the 'Eligibility Details Dashboard'.
Our suite of Dashboard Reports include:
Eligibility Details Dashboard
Medical Claims Details Dashboard
Pharmacy Claims Details Dashboard
Dental Claims Details Dashboard
Hospital Admissions Details Dashboard
Member Registries Details Dashboard
Obstetrics Details Dashboard
Quality Measures Details Dashboard
Each Dashboard distills its corresponding core table into foundational metrics, offering you a panoramic view of the encompassed data. Yet, they don't just stop at summarization. The true strength of these Dashboards lies in their navigational depth. With a single click, you can transition from high-level overviews to the granular specifics of any metric, ensuring that every analysis is backed by tangible, justifiable data.
Other Reports
Other reports are named based on their contents and do not follow any specific rule.
General Parameters or Controls
Upon accessing the reports, you'll find parameters (or controls) situated at the top, designed to facilitate customization of the displayed information to meet individual requirements. To view these parameters, it may be necessary to click the arrow positioned in the upper right corner. While each report possesses its unique set of parameters tailored to its content, there are several parameters that are consistently present across the majority of reports. Below is a list, accompanied by definitions, of these recurrent parameters:
Organization Name: Represents the entity or organization to which the data belongs. In most instances, there is no need to adjust this parameter.
Healthcare Model Name: Refers to the specific healthcare model in question, such as GHP, Medicare Advantage, etc. If you're navigating data from multiple healthcare models, you might need to select a specific one for targeted analysis.
Group Level 02, 04, 05, 07 Name: These act as population-based filters. For instance, 'Group Level 02' might pertain to Regions, 'Group Level 04' to Super Primary Medical Groups, 'Group Level 05' to Primary Medical Groups, and 'Group Level 07' to Primary Care Physicians. Selecting a specific level will consequently filter the displayed data based on the chosen population segment. On expanding any of these parameters, its content will clarify the exact population it addresses, as illustrated in the provided example.
General Metrics Definition
Our Dashboard display several metrics in a divers set of context. Generally speaking, a metric is a quantifiable measure used to track and assess the status of a specific process, performance, or objective. Within a dashboard, metrics are presented as data points, often summarized and visualized in various forms such as numbers, charts, and graphs. They provide a clear snapshot of performance, allowing stakeholders to make informed decisions. Metrics are essential for monitoring progress, identifying trends, and facilitating comparisons, ensuring that goals and standards are met. Each dashboard have individual metrics within the context of the Dashboard, but some of them are used in several dashboard with the same definition (let's call them General Metrics). Here are the definition of the General Metrics. These definitions will prevail unless defined within the scope of the definition of a particular Dashboard or on the Dashboard itself.
General Definitions:
IBNR - Incurred but Not Reported - This is an actuarial amount to project the dollar value of the services rendered but not yet paid by the Plan.
PMPM - Per Member Per Month. This is the economic value divided by the Members (i.e. population) of a specific period. For example, Medical Cost PMPM, Pharmacy Cost PMPM, etc...
Per Thousand (also, per K) - This is the numeric value divided by the Members (i.e. population) and multiplied by 1000. That is, the numeric value per 1000 patients. For example, Admissions per Thousand, ER per Thousand, etc...
Eligibility Metrics:
Members - The total members accounting also for the fraction of members in a particular period. For example, if a member is half of the month it is sum as 0.5 instead of one. The member is counted per month, so, if the period includes more than one month, the member will be sum (1 for the whole month or the fraction if not the whole month) for all months that the member is eligible. For example, if the period is one year and the member is eligible the whole year, the Members calculation for this member will be 12. This metric source is Eligibility. Usually, from this metric you can drill down to the Eligibility Details within the specific context.
Unique Members - The unique count of members in a particular period. This is a count, so, if the member is only a portion of the month will be counted as 1. The same happens if the member is eligible the whole month. This unique count counts only once the member for the whole period. For example, if the period is one year and the member is eligible the whole year, the Unique Count calculation for this member will be 1.
Financial:
Revenue - This is the total premium received per each member.
Budget - This is the portion of the revenue that is designated to cover medical cost.
RAF (also, Member RAF) - Risk Adjustment Factor. This is a number that is provided by member from the Plan and affects the Revenue (i.e. Premium) assigned to each member.
Medical Claims Metrics:
Admissions - The total admissions in hospitals sourced from Medical Claims. From here, you can drill down to the Medical Claims Details, filtered by Admissions within the specific context.
Readmissions - The total re-admissions in hospitals sourced from Medical Claims. A readmission is an admission that have a previous admission, for the same patient, within the previous 30 days. From here, you can drill down to the Medical Claims Details, filtered by Admissions within the specific context.
% Readmissions (or % Read) - The total re-admissions divided by the total admissions in a percentage format.
ALOS - Stands for the Average Length of Stay in hospitals based on Medical Claims.
ER Visits - The visits to ER sourced from Medical Claims. A visit is counted once per member per day. From here you can drill down to Medical Claims Details filtered by ER within the specific context.
Births - The total count of births from Medical Claims.
Cesarean - The total count of births that were cesarean from Medical Claims.
% Cesarean - The total count of births that were cesarean divided by the total count of births.
Pharmacy Claims Metrics:
Drugs - The total count of drugs (lines of service) sourced from Pharmacy Claims.
Generic - The total count of drugs (lines of service) that are Generic sourced from Pharmacy Claims.
% Generic - The total count of drugs (lines of service) that are Generic divided by the total count of drugs (lines of service) sourced from Pharmacy Claims.
Preauthorization Metrics:
Preauthorizations - The total count of preauthorizations sourced from the Preauthorizations.
Preauthorizations Denied - The total count of preauthorizations with status Denied sourced from the Preauthorizations.
% Preauthorizations Denied - The total count of preauthorizations with status Denied divided by the total count of preauthorizations sourced from the Preauthorizations.